Screening and suicide risk factors in the major depression of adults ✓

Screening of depression is not generally recommended, given that there are reasonable doubts about its effectiveness for modifying the course of the illness if it is not accompanied by follow-up measures.

✓

The possibility of a depressive pathology in persons with risk factors must be taken into account.

B

The questionnaires to be used should include at least two questions referring to the person’s mood and ability to enjoy.

✓

In any patient with a major depressive disorder, it is advisable to explore ideas of death and intent to inflict self-harm.

✓

The clinical history of a patient with major depression must always include previous attempts to inflict self-harm.

✓

In patients with a high risk of suicide, it is advisable to seek frequent, additional support and to assess sending them urgently to a mental health specialist.

✓

Hospitalisation should be considered for patients with a high risk of suicide.

Pharmacological treatment of depression A

Antidepressant drugs represent a first line of treatment for moderate or severe depression.

✓

For mild depression, other therapeutic strategies can be considered before antidepressant drugs.

D

The use of drugs is recommended for those patients with mild depression and a history of moderate or severe episodes of depression.

D

The use of drugs is recommended for mild depression when other medical illnesses or associated comorbidity may be present.

✓

It is advisable to set up an appointment within 15 days for any patient with depression who does not receive pharmacological treatment.

A

SSRIs are recommended as drugs of first choice in the treatment of major depression.

B

In the event that an SSRI drug is not well-tolerated due to the appearance of adverse effects, it should be switched to another drug of the same group.

A

An SSRI should be prescribed for patients who may receive treatment with any tricyclic antidepressant and who do not tolerate it.

✓

TCAs are an alternative to SSRIs if a patient has not tolerated at least two drugs from this group or is allergic to them.

✓

New drugs could be used in the event of intolerance to SSRIs, thereby using the profile of their adverse effects as a guideline.

12

Specific patient profiles could warrant different drugs, thereby using the adverse effects rather than their efficacy as a guideline. Venlafaxine should be considered as a second line of treatment in patients with major depression.

✓

Before starting antidepression treatment, a healthcare professional should adequately inform the patient about the expected benefits; the frequent, infrequent and patientspecific side effects that could arise, in both the short and the long-term; and especially about the duration of the treatment.

✓

It is especially advisable to inform about a possible delay in the therapeutic effect of antidepressants.

✓

Patients receiving antidepressant drug treatment must be closely monitored, at least during the first 4 weeks.

✓

All patients who show moderate major depression and who are treated with antidepressant drugs must be assessed again before 15 days after initiating treatment.

✓

All patients who show severe major depression and who receive outpatient treatment with antidepressant drugs must be assessed again before 8 days after initiating treatment. Pharmacological treatment must be maintained in all patients for at least 6 months after remission. In patients with any previous episode or the presence of residual symptoms, the treatment must be maintained for at least 12 months after remission.

✓

In patients with more than 2 previous episodes, the treatment must be maintained for at least 24 months after remission. The dose of the drug used during the maintenance phase must be similar to the dose used to achieve remission. In patients with a partial response at the third or fourth week of treatment, it is

✓ - To increase the dose of the drug up to the maximum therapeutic dose.

✓

For a patient who does not improve with the initial drug treatment for depression, it is advisable: - To revise the diagnosis of depressive disorder. - To verify that the treatment is being followed. - To confirm that the antidepressant is being taken at the right time and dose. If the patient does not improve at the third or fourth week, any of the following strategies could be followed: - Switching from an antidepressant to any family, including another serotonergic. - Combining antidepressants. - Augmenting the initiated treatment with lithium or triiodothyronine. It is not advisable to increase the SSRI dose if there is no response after 3 weeks of treatment. 13

C

The association of SSRI with mirtazapine or option, but thereby taking into account the possibility of greater adverse effects. There is insufficient information available to recommend an increase in the dose of tricyclic antidepressants in non-responders.

✓

In the event of resistance to various treatments according to the aforementioned guidelines, assess the use of MAOIs. There is insufficient data for recommending augmentation with

✓

✓

Psychological interventions should be provided by professionals who have experience at managing depression and who are experts in the applied therapy. This is especially important in the most severe cases. In mild and moderate depression, specific and brief psychological treatment (such as problem-solving therapy, cognitive behavioural therapy or counselling) in 6 to 8 sessions during 10-12 weeks should be considered. The preferred psychological treatment for moderate, severe or resistant depression is cognitive behavioural therapy. Interpersonal therapy can be considered as a reasonable alternative. For moderate and severe depression, suitable psychological treatment should include 16 to 20 sessions during at least five months. For moderate depression, either antidepressant drug treatment or suitable psychological intervention can be recommended. Cognitive behavioural therapy should be offered to patients with moderate or severe depression who reject drug treatment or for whom avoiding the secondary effects of antidepressants is a clinical priority or who express that personal preference. Couples therapy should be considered, if applicable, in the event that a suitable response is not obtained with previous individual intervention. Cognitive behavioural therapy should be considered for patients who have not had a suitable response to other interventions or who may have a prior history of relapses or residual symptoms, despite treatment. Cognitive behavioural therapy should be considered for patients who have recurrent depression and who have relapsed despite antidepressant treatment or who express a preference for psychological treatment. 14

For patients whose depression is resistant to pharmacological treatment and/or who have multiple episodes of recurrence, a combination of antidepressants and cognitive behavioural therapy should be offered. A combination of cognitive behavioural therapy and antidepressant medication should be offered to patients with chronic depression. Whenever cognitive behavioural therapy is applied to more severe patients, the techniques based on behavioural activation should be given priority. Psychological interventions other than the aforementioned could be useful for dealing with comorbidity or the complexity of the family relationships frequently associated with the depressive disorder.

Electroconvulsive therapy should be considered as a therapeutic alternative in adults with severe major depression.

✓ ✓

ECT is especially indicated for patients with severe major depression (with a high risk of suicide or severe physical impairment) in resistant depression and by informed choice of the patient. In general, guided self-help is not recommended for patients with severe major depression. However, for patients with mild or moderate depression, professionals could consider recommending guided self-help programmes based on cognitive behavioural therapy.

✓

Participation in support groups is not considered an effective treatment measure in patients with the major depression disorder, either alone or combined with other therapeutic measures. Programmes of structured and supervised exercise of moderate intensity, with a frequency of 2-3 times per week, with a duration of 40-45 minutes and for a period of 10 to 12 weeks should be recommended to patients with mild-moderate depression.

✓

The existing scientific evidence does not allow recommending the use of acupuncture as a treatment for major depression. The use of St John’s Wort is not recommended as a treatment option for patients with major depression.

✓

Health professionals should inform patients who consume it about the possible risks and benefits.

15

- Underdiagnosis of major depression.

✓

- Follow-up on treatment with antidepressants. - Maintenance of treatment with antidepressants. - Efficient use of antidepressant drugs. - Psychotherapeutic treatment in severe major depression. - Psychotherapeutic treatment in mild major depression.

16